Medicare, Fees, and Parity

Clinician Coverage and Outpatient Mental Health Services: Medicare covers needed diagnostic and treatment services provided by physicians, including psychiatrists, as well as clinical psychologists, social workers, psychiatric nurse specialists, nurse practitioners and physicians assistants. In order for Medicare to reimburse these clinicians, they must be certified as participants accepting Medicare. Brief visits for the purpose of monitoring the efficacy of prescribed medications are Medicare-covered. Medicare also covers needed outpatient mental health services including individual and group therapy, therapeutic activity programs, family counseling and patient education services, drugs which a patient generally cannot self-administer and diagnostic tests, including lab testing.

The Medicare statute itself places no limits on clinician coverage as long as the services provided are medically necessary. However, many Part B carriers have Local Medical Review Policies (LMRPs, also known as Local Coverage Determinations, or LCDs) setting out the number of visits Medicare will cover for mental health services. As a result of these policies, an individual may be told Medicare will not pay for doctor and other visits his providers consider to be medically necessary. The individual should appeal any denial of coverage that he or she believes is based on a LMRP rather than on his or her individual medical needs.

Elimination of Discriminatory Copayment Rates for Medicare Outpatient Psychiatric Services. Cost sharing for outpatient mental health services will be phased down from 50 percent to 20 percent by 2014. Cost sharing will be 45 percent in 2010 and 2011, 40 percent in 2012, 35 percent in 2013, and 20 percent in 2014 and thereafter.

* Adjustment for Medicare Mental Health Services. For the period of July 1, 2008 through December 31, 2009, Medicare psychotherapy codes will be increased by 5 percent. This will effectively reverse some of the payment reductions that occurred as a result of the budget-neutral implementation of the most recent five-year review of relative values.